Laparoscopic Common Bile Duct Exploration Followed by Primary Suture Using a Modified Bile Duct Incision

Traditional common buildup exploration may lead to complications, like biliary stricture and leakage. We try to reduce the incidence rate of surgical complications by proposing a modified incision. We propose a modified medical incision, starting from the cystobiliary junction to the CBD with the lengths of only five millimeters to 10 millimeters.

The shorter incision in our protocol means less damage to the CBD, which can lead to lower pulse-operated biliary leakage as stenosis rate. This approach improves applicability to a broader population, including those with non-dilated cystic ducts.

[Narrator] To begin, place the patient in a supine position with the head elevated at 30 degrees. Administer general anesthesia via a laryngeal mask or tracheal intubation. Position the surgeon and second assistant to the left of the patient, at the head and foot respectively, and the first assistant to the right of the patient. Then, insert the subumbilical trocar for the camera, and under direct vision, establish the epigastric port, right midclavicular port, and right anterior axillary line. Position the patient in a 20-degree reverse Trendelenburg with a left lateral tilt for better visualization. Maintain pneumoperitoneum at 12 millimeters of mercury to create working space. Grasp the neck of the gallbladder, or Hartmann's pouch with grasping forceps. Apply traction in the right upper direction. Incise the serosa overlying the cystic duct. Then, clear the lymphatic tissue and skeletonize the cystic artery. Ligate the cystic artery, then dissect the cystic duct completely up to the cystobiliary junction. With atraumatic graspers, engage the seromuscular layer of the proximal cystic duct, avoiding full thickness compression. Apply anterolateral traction to achieve optimal cystic duct to common bile duct angulation. Apply locking clips in the distal cystic duct to temporarily prevent bile flow. Use electric hooks or scissors to make a microlongitudinal incision along the cystobiliary junction, extending toward the common bile duct. Then, adjust the incision size between five millimeters to 10 millimeters depending on the stone size. Perform choledochoscopy using a three-millimeter or five-millimeter choledochoscope depending on the diameter of the cystic duct. Remove common bile duct stones using a basket. If impacted stones at the papilla obstruct access, employ electrohydraulic lithotripsy to fragment the stones. And collect them later using the basket. Reconfirm the clearance of common bile duct stones. Verify that irrigation water flows smoothly through the common bile duct and the sphincter of Oddi is functioning properly. Close the incision from the cystobiliary junction to the anterior wall of the common bile duct using a 5-0 polydioxanone suture. Apply clips to close the proximal cystic duct and cut the distal end. Then, remove the gallbladder completely. Confirm that there is no bile leakage or stenosis. Then, place a drainage tube near the common bile duct and pull it out through the right anterior axillary line port. Higher numbers of patients in the LCBDE + LC group had elevated liver function tests, jaundice, and acute cholangitis before surgery. No patient in the modified micro incision group developed biliary stenosis, residual stones, or surgery-related death, whereas two patients in the traditional group experienced bile duct stenosis.